加强多学科合作,不断提高颅底神经外科诊治水平

正近二十年来,国内学者对颅底神经外科的认识不断加强,技术不断改良,复杂手术种类和数量日益增多,如岩斜区肿瘤、颅咽管瘤、听神经瘤全切技术日益完善,面听神经保存率不断提高。但真正系统开展颅底神经外科手术仍集中在国内较大的神经外科中心,主要原因在于对人员梯队、设备和团队合作的要求甚高,包括重症监护,尤其多学科合作水平。     

大力推广显微神经外科手术提高神经外科治疗水平

大力推广显微神经外科手术　提高神经外科治疗水平陈明振随着ＣＴ、ＭＲ、ＤＳＡ等高科技技术的不断问世，对神经外科疾病的诊断水平不断得到提高，使神经外科医生在术前多能做到精确的定位诊断。但如何提高手术的治疗水平却是每个专业医师面临解决的主要问题。显微神经外...     

不断提高直肠癌手术并发症诊治水平

直肠癌手术相关并发症包括术后早期的副损伤、出血、感染、吻合口漏,以及后期的排便功能、排尿功能、性功能障碍和造口并发症等。一旦发生有些并发症处理起来十分困难。因此,重视其术前的预防,以减少并发症的发生更为重要。提高手术并发症的早期诊断与及时有效的正确处理水平,是降低手术病死率、改善患者生存质量的关键。     

神经外科麻醉专科医师培养体系的建立与实施

<正>神经外科学发展迅猛、日新月异,特别是基础研究领域成果呈指数增长,不仅涉及细胞和分子水平,同时实现了纳米技术和神经计算机接口技术在该领域的广泛应用[1],由此带来神经外科学各个亚专业领域飞速的发展、专科疾病治疗范围的不断扩大和效果的长足进步。神经外科技术已由显微神经外科、微创神经外科发展到精准神经外科[2,3]。但纵观全世界,目前尚无神经外科麻醉专科医师培训课程,本文就该专科培训体系建立的必要性和可行性     

加强肝移植围手术期处理,提高生存率

近年肝脏移植在国内大、中医院广泛开展,但由于我国开展肝移植时间较短,各单位施行例数差别大,临床肝移植经验尚待积累。尽管如此,在我国一些大的中心围手术期生存率已接近或达到国际水平。我院自1999年2月至2003年9月连续施行肝移植137例,术后住院期间死亡11例,生存率为92%。术后直接死亡原因包括肺部感染6例,肾功能衰竭2例,颅内出血2例,应激性溃疡穿孔、全腹膜炎、多器官衰竭1例。长期随访显示良性肝病1、3年生存率为87.46%及80.59%,恶性肝病1、2年生存率为87.45%及65.59%。本文拟结合我院病例,讨论提高肝移植围手术期生存率的体会。受体…     

不断提高胃癌手术消化道重建规范化水平

诸多的消化道重建方法,因并发症、生活质量等问题,促使临床不断地探索高质量的更为生理的重建方式。建立在根治性手术基础上的重建,安全、低侵袭,重建脏器的血液循环良好,减少吻合口的数目,避开胰瘘时对吻合口构成的威胁,是重建的最基本的要求。繁杂的重建方式易引发的各种并发症、研究阶段的方法应慎选。预防胃液、肠液的返流。保留贮存、排空食物的功能以及食物经生理通路,术后能内镜下行胆道、胰腺、残胃的检查无疑对于患者长远的生活质量和经济利益具有重要意义。除此而外,术者重建技术水准也应成为选择术式的基本条件。吻合缝合技术是不容忽视的,良好的吻合缝合技术是成功的重建的基本保障。     

大力开展关节镜技术,不断提高关节创伤的诊疗水平

关节镜技术是20世纪骨科领域最重要的技术革命之一,其广泛开展极大地提高了关节创伤的诊疗水平.20世纪70年代以后,随着现代科技的进步、新器械的不断开发,关节镜技术发展迅速,由于其具有创伤小、恢复快、并发症少等优点,目前除关节置换手术外,关节镜下微创手术已基本取代关节切开术.     

不断提高疝病的规范化诊治水平

随着疝修补技术的不断发展,规范化治疗的问题已得到更进一步的认识,中华医学会疝和腹壁外科学组在2001年和2003年制订了我国疝外科专业的学术指南。《成人腹股沟疝和股疝治疗方案》和《腹壁切口疝治疗方案》。并于2012年6月对其进行了全面修订,并更名为《中国腹壁疝诊疗指南(2012版)》,为我国疝外科领域的规范化提出了较为系统的理论依据。疝和腹壁外科学组和中国医师协会外科医师分会疝和腹壁外科专委会联合,于2013年12月制定了《成人腹股沟疝,股疝,腹壁切口疝诊断和治疗质量控制标准》。我国《指南》和《质量控制标准》的出台,其主要目的是根据长期的诊治经验和临床数据,制定出一些有规律性的建议供医生参考。同时作为一个行业标准,是医疗技术、管理方法及其经济效益概念的综合体现,将最终产生医疗效果。     

加强胃癌的基础研究,提高防治水平

恶性肿瘤最根本的特征是细胞失控性生长,后者源于细胞的去分化状态,容易进入或不易脱出细胞增殖周期、“病理”性复制、不易衰老或死亡。肿瘤细胞的基本生命活动受控于多种高度保守的基因及其产物(如癌基因、抑癌基因、细胞死亡基因、DNA修复基因、转移基因等),它们构成细胞之间、跨细胞膜、细胞内的信号传导,调控着基因转录、翻译、蛋白质修饰(如蛋白质折叠、磷酸化/去磷酸化、蛋白质裂解、泛肽化等)和细胞周期。　　多种遗传物质的改变包括抑癌基因的失活、原癌基因的激活、端粒酶的复活在肿瘤形成过程中均起重要作用。癌基因与抑癌…     

不断提高我国克罗恩病的诊治水平

克罗恩病（Crohn’s disease,CD）是一种胃肠道的慢性、反复发作性和非特异性的全肠壁炎,病变呈节段性分布,可累及消化道任何部位。近年来我国报道CD病例明显增多,据推测中国大陆地区,     

加强科学性、探索新技术、不断提高脊柱侧凸的治疗水平

加强科学性、探索新技术、不断提高脊柱侧凸的治疗水平邱贵兴自从１９６０年Ｈａｒｒｉｎｇｔｏｎ内固定器问世以来，脊柱侧凸的治疗技术日新月异．国内的发展更为迅速，国际上流行的各种新器械、新手术，很快就能在全国推广应用．而且通过临床实践，这些新方法还得到了不...     

再论全麻下坐位神经外科手术的处理

坐位下施行后颅窝和颈椎手术,有手术野暴露好、脑压低、出血少的优点,但麻醉处理有一定特殊性。30年来我院共施行全麻下坐位手术370例,讨论如下。资料及方法男215例,女155例,年龄7～64岁,其中15岁以下14例,61岁以上4例,手术种类:小脑肿瘤88例,听神经瘤59例,颈脊髓肿瘤56例(其中18例瘫痪),第四脑室肿瘤19例,第三脑室肿瘤16例,三叉神经切断16例,梗阻性脑积水12例,颅底陷入症11例,颈椎病10例,其它后颅窝或颈椎疾病84例。     

颅内动脉瘤与脑血管畸形手术的麻醉处理

在颅内动脉瘤与脑血管畸形的病人中,由于病理生理和手术操作上的特点,对麻醉有一定要求,现结合我院49例次麻醉的资料分析讨论如下:临床资料本组41例共行49次手术,其中颅内动脉瘤26例,脑血管畸形15例。年龄最小11岁,最大70岁。动脉瘤以41～60岁屋多,占63％;脑血管畸形则以20～40岁为主,占66％。动脉瘤的部位在颅内动脉后交通枝者16例;在大脑前动脉和前交通枝者2例;位于大脑中动脉者5例;位于基底动脉干者1例;多发性动脉瘤2例。手术方式包括动脉瘤蒂夹闭术,动脉瘤肌片包裹加固术;动脉瘤孤立术,畸形血管团切除加血肿     

神经外科坐位手术时气栓的预防和处理

后颅窝、颈椎和枕叶等部位疾患采用坐位进行手术的主要优点,在于脑脊液和血液自然地离开手术区,改善静脉引流,减少出血,手术野干净清晰,这比在显微镜下去进行很多手术更为重要。可是坐位对麻醉医师来说产生了许多问题,特别是低血压,更可怕的是气栓。因此提出减少气栓发生的原因和降低发生率或严重程度的预防措施及改进麻醉方法。     

神经外科手术麻醉时急性脑肿胀的处理

神经外科手术以颅脑外伤及颅内肿瘤摘除术为多见,手术时对脑组织的挤压,病人的体位,气道不够通畅,缺氧或二氧化碳蓄积,输血输液逾量,麻醉药物本身的影响,肌肉松弛剂使用不当以及手术操作粗糙等均可出现急性脑肿胀(tight brain),给手术造成很大困难,引起脑肿胀的原因也可为肿瘤本身所致,如瘤内突然出血等。脑肿胀临床特     

加强围手术期处理提高胰十二指肠切除术的安全性

<正> 胰十二指肠切除术是一种严重并发症发生率高、死亡率高的手术。手术的成功直接取决于手术期间的技术操作,围手术期处理如营养支持,对于确保胰十二指肠切除的成功和达到预期治疗的目的具有十分重要的临床意义。本文就我院1991年～2001年施行胰十二指肠切除术48例,围手术期体会报告如下。     

不同麻醉方法对神经外科手术患者脑血管自身调节功能影响的比较

Objective To compare the effect of different methods of anesthesia on cerebral autoregulation in patients undergoing neurosurgery.Methods Sixty-nine ASA Ⅱ orⅢ patients with brain tumor, aged 23-62 yr, scheduled for neurosurgery under general anesthesia, were randomly divided into 3 groups ( n = 23 each) : propofol-remifentanil group (group PR), sevoflurane-remifentanil group (group SR) and propofol-sevoflurane-remifentanil group (group PSR) . Anesthesia was induced with target-controlled infusion (TCI) of propofol (target plasma concentration3 μg/ml, PR and PSR groups) or inhalation of 8% sevoflurane (group SR) and iv injection of remifentanil 1 mg/kg and atracurium 0.5 mg/kg. The patients were mechanically ventilated after tracheal intubation. PETCO2 was maintained at 32-35 mm Hg. Anesthesia was maintained with TCI of propofol (target plasma concentration 2.0-3.5 μg/ml) in group PR, with inhalation of 1.5%-2.5% sevoflurane in group SR, with TCI of propofol (target plasma concentration 1.5-3.0 μg/ml) and inhalation of 1% sevoflurane in group PSR, and with TCI of remifentanil (target plasma concentration 2.0-4.5 ng/ml) and iv infusion of atracurium at 6 μg · kg-1 · min-1 in all groups. Auditory evoked potential index was maintained between 40-45. The middle cerebral artery time-average peak flow velocity was recorded before induction (baseline) , immediately after intubation, immediately before craniotomy and at the beginning of skin suture. The unilateral carotid artery was compressed for 7 s at the corresponding time points mentioned above. The transient hyperemic response ratio (THRR) was calculated to reflect cerebral autoregulation. Results Compared with the baseline value at T0, THRR was significantly increased at T2in group PR and decreased at T2,3 in group SR (P <0.05) ,while no significant change was found in THRR at T1-3in group PSR (P >0.05). The THRR was significantly lower in SR and PSR groups than in group PR, and higher in group PSR than in group SR ( P < 0.05). Conclusion Propofol-remifentanil anesthesia can improve cerebral autoregulation, sevoflurane-remifentanil anesthesia can reduce cerebral autoregulation, and propofol-sevofluraneremifentanil anesthesia exerts no effect on cerebral autoregulation in patients undergoing neurosurgery.     

不同麻醉方法对神经外科手术患者脑血管自身调节功能影响的比较

目的 比较不同麻醉方法对神经外科手术患者脑血管自身调节功能的影响.方法 拟行颅脑肿瘤切除术患者69例,ASA分级Ⅱ或Ⅲ级,年龄23～62岁,采用随机数字表法,将患者随机分为3组(n=23):异丙酚-瑞芬太尼复合麻醉组(PR组)、七氟醚.瑞芬太尼复合麻醉组(SR组)和异丙酚-七氟醚-瑞芬太尼复合麻醉组(PSR组).麻醉诱导:PR组和PSR组TCI异丙酚,血浆靶浓度为3μg/ml;SR组吸入8%七氟醚;3组均静脉注射瑞芬太尼1 mg/kg和阿曲库铵0.5 mg/kg.气管插管后机械通气,维持PETCO2 32～35 mm Hg.麻醉维持:PR组TCI异丙酚,血浆靶浓度2.0～3.5/μg/ml,SR组吸入1.5%～2.5%七氟醚,PSR组TCI异丙酚(血浆靶浓度1.5～3.0 μg/ml)复合吸入1%七氟醚,3组均TCI瑞芬太尼(血浆靶浓度2.0～4.5 ng/ml),静脉输注阿曲库铵6 μg·kg-1·min-1,维持听觉诱发电位指数值40～45.分别于麻醉诱导前(基础状态,T0)、气管插管后即刻(T1)、打开颅骨前即刻(T2)及开始缝皮时(T3)记录大脑中动脉时间-平均峰值流速,于相应时点压迫一侧颈总动脉7 s,计算脑短暂充血反应率(THRR),以反映脑血管自身调节功能.结果 与T0时比较,PR组T2时THRR升高,SR组T2,3时THRR降低(P<0.05),PSR组THRR差异无统计学意义(P>0.05).与PR组比较,SR组和PSR组THRR降低(P<0.05);与SR组比较,PSR组THRR升高(P<0.05).结论 异丙酚-瑞芬太尼复合麻醉可提高神经外科手术患者脑血管自身调节功能,七氟醚-瑞芬太尼复合麻醉可降低其脑血管自身调节功能,异丙酚-七氟醚-瑞芬太尼复合麻醉对其脑血管自身调节功能无影响.

Abstract：

Objective To compare the effect of different methods of anesthesia on cerebral autoregulation in patients undergoing neurosurgery.Methods Sixty-nine ASA Ⅱ orⅢ patients with brain tumor, aged 23-62 yr, scheduled for neurosurgery under general anesthesia, were randomly divided into 3 groups ( n = 23 each) : propofol-remifentanil group (group PR), sevoflurane-remifentanil group (group SR) and propofol-sevoflurane-remifentanil group (group PSR) . Anesthesia was induced with target-controlled infusion (TCI) of propofol (target plasma concentration3 μg/ml, PR and PSR groups) or inhalation of 8% sevoflurane (group SR) and iv injection of remifentanil 1 mg/kg and atracurium 0.5 mg/kg. The patients were mechanically ventilated after tracheal intubation. PETCO2 was maintained at 32-35 mm Hg. Anesthesia was maintained with TCI of propofol (target plasma concentration 2.0-3.5 μg/ml) in group PR, with inhalation of 1.5%-2.5% sevoflurane in group SR, with TCI of propofol (target plasma concentration 1.5-3.0 μg/ml) and inhalation of 1% sevoflurane in group PSR, and with TCI of remifentanil (target plasma concentration 2.0-4.5 ng/ml) and iv infusion of atracurium at 6 μg · kg-1 · min-1 in all groups. Auditory evoked potential index was maintained between 40-45. The middle cerebral artery time-average peak flow velocity was recorded before induction (baseline) , immediately after intubation, immediately before craniotomy and at the beginning of skin suture. The unilateral carotid artery was compressed for 7 s at the corresponding time points mentioned above. The transient hyperemic response ratio (THRR) was calculated to reflect cerebral autoregulation. Results Compared with the baseline value at T0, THRR was significantly increased at T2in group PR and decreased at T2,3 in group SR (P <0.05) ,while no significant change was found in THRR at T1-3in group PSR (P >0.05). The THRR was significantly lower in SR and PSR groups than in group PR, and higher in group PSR than in group SR ( P < 0.05). Conclusion Propofol-remifentanil anesthesia can improve cerebral autoregulation, sevoflurane-remifentanil anesthesia can reduce cerebral autoregulation, and propofol-sevofluraneremifentanil anesthesia exerts no effect on cerebral autoregulation in patients undergoing neurosurgery.     

不同麻醉方法对神经外科手术患者脑血管自身调节功能影响的比较

Objective To compare the effect of different methods of anesthesia on cerebral autoregulation in patients undergoing neurosurgery.Methods Sixty-nine ASA Ⅱ orⅢ patients with brain tumor, aged 23-62 yr, scheduled for neurosurgery under general anesthesia, were randomly divided into 3 groups ( n = 23 each) : propofol-remifentanil group (group PR), sevoflurane-remifentanil group (group SR) and propofol-sevoflurane-remifentanil group (group PSR) . Anesthesia was induced with target-controlled infusion (TCI) of propofol (target plasma concentration3 μg/ml, PR and PSR groups) or inhalation of 8% sevoflurane (group SR) and iv injection of remifentanil 1 mg/kg and atracurium 0.5 mg/kg. The patients were mechanically ventilated after tracheal intubation. PETCO2 was maintained at 32-35 mm Hg. Anesthesia was maintained with TCI of propofol (target plasma concentration 2.0-3.5 μg/ml) in group PR, with inhalation of 1.5%-2.5% sevoflurane in group SR, with TCI of propofol (target plasma concentration 1.5-3.0 μg/ml) and inhalation of 1% sevoflurane in group PSR, and with TCI of remifentanil (target plasma concentration 2.0-4.5 ng/ml) and iv infusion of atracurium at 6 μg · kg-1 · min-1 in all groups. Auditory evoked potential index was maintained between 40-45. The middle cerebral artery time-average peak flow velocity was recorded before induction (baseline) , immediately after intubation, immediately before craniotomy and at the beginning of skin suture. The unilateral carotid artery was compressed for 7 s at the corresponding time points mentioned above. The transient hyperemic response ratio (THRR) was calculated to reflect cerebral autoregulation. Results Compared with the baseline value at T0, THRR was significantly increased at T2in group PR and decreased at T2,3 in group SR (P <0.05) ,while no significant change was found in THRR at T1-3in group PSR (P >0.05). The THRR was significantly lower in SR and PSR groups than in group PR, and higher in group PSR than in group SR ( P < 0.05). Conclusion Propofol-remifentanil anesthesia can improve cerebral autoregulation, sevoflurane-remifentanil anesthesia can reduce cerebral autoregulation, and propofol-sevofluraneremifentanil anesthesia exerts no effect on cerebral autoregulation in patients undergoing neurosurgery.